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The Case for Cost-Effectiveness in Universal Health Coverage: Prioritizing Key Services

This analysis by Toby Ord, a research fellow at Oxford University, emphasizes the importance of cost-effectiveness in the realm of universal health coverage. Prioritizing key services, such as vaccination, maternal care, and child health, is crucial for maximizing health benefits within limited budgets. The disparities in cost-effectiveness across various interventions can lead to significant differences in health outcomes. By adopting a cost-effective approach, countries can save more lives and optimize public health resources, ensuring that health systems work efficiently for all populations.

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The Case for Cost-Effectiveness in Universal Health Coverage: Prioritizing Key Services

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  1. Choosing services The case for cost-effectiveness Toby Ord Research Fellow, Oxford University President, Giving What We Can

  2. Key services • Universal coverage is defined in terms of access to key services • Countries moving towards universal coverage must therefore identify what services are key • Also need to prioritize among these key services when expanding the range of services accessible at an affordable cost

  3. Examples • Typically targets the whole population or the part which is least likely to obtain affordable access to a comprehensive package • Package of minimum, basic, or essential services or benefits • Ghana, Nigeria, Rwanda, Vietnam, Mexico • Typically emphasize: • Vaccination, child health, maternal care

  4. Prioritization

  5. Cost-effectiveness • Sounds boring, but it is the core of what health systems are about • Effectiveness = health benefit • Cost-effectiveness = providing the most health benefit for a given budget • We typically measure health benefit in DALYs • A measure of the years of life saved and morbidity prevented

  6. Cost-effectiveness • Some interventions deliver much more health benefit for a given budget • It is not a matter of 10% better or 50% better • but hundreds or thousands of times better • It isn’t the only important thing, but it is the core

  7. What does a DALY cost? Treatment of Kaposi’s Sarcoma Antiretroviral therapy £20,000 / DALY barrier

  8. What does a DALY cost? Treatment of Kaposi’s Sarcoma Antiretroviral therapy Prevention of transmissionduring pregnancy

  9. What does a DALY cost? Treatment of Kaposi’s Sarcoma Antiretroviral therapy Prevention of transmissionduring pregnancy

  10. What does a DALY cost? Treatment of Kaposi’s Sarcoma Antiretroviral therapy Prevention of transmissionduring pregnancy Distribution of condoms

  11. What does a DALY cost? Treatment of Kaposi’s Sarcoma Antiretroviral therapy Prevention of transmissionduring pregnancy Distribution of condoms

  12. What does a DALY cost? Treatment of Kaposi’s Sarcoma Antiretroviral therapy Prevention of transmissionduring pregnancy Distribution of condoms Distribution of bed nets

  13. What does a DALY cost? Treatment of Kaposi’s Sarcoma Antiretroviral therapy Prevention of transmissionduring pregnancy Distribution of condoms Distribution of bed nets

  14. Dramatic differences in cost-effectiveness (DALYs per $1,000)

  15. Facts about the CE distribution • If you funded them equally, the top 20% would produce 80% of the value • The best intervention is 10,000 times better than the worst • The best intervention is 100 times better than the median • If you choose two at random, on average one is 100 times better

  16. How important is cost-effectiveness? • Prioritizing on cost-effectiveness is: • The difference between saving a life and saving 100 lives • Failure to prioritize on cost-effectiveness is: • Letting 100 die to save 1 • ‘Not seeing the forest for the trees’ • Squandering 99% of the value we could produce • Wasting public funds • Unfairly privileging the few at the expense of the many • Helping the rich or powerful at the expense of the poor • Example: spending $1m on dialysis instead of on DOTS • Buying 20 years of life for some at the expense of 20,000 years for others

  17. The biggest moral issue in global health • Not the most exciting • Not the most philosophically interesting • Not the most technically interesting or challenging • But the core of the issue • (Actually securing large amounts of good health for the public) • It should be the starting point for priority setting

  18. Other concerns (GPS Health) • Severity of health condition • Realization of potential • Past health loss • Rarity of health condition • Socio-economic status • Area of residence • Sex and gender • Race, ethnicity, religion • Productivity • Care for others • Catastrophic health expenditure

  19. Quantitative combinations of criteria Basic approach 0 4 7 9 2 1 3 5 6 8 Cost per DALY (multiples of GNI / capita)

  20. Quantitative combinations of criteria Basic approach 0 4 7 9 2 1 3 5 6 8 Cost per DALY (multiples of GNI / capita) UK approach (NICE) 0 4 7 9 2 1 3 5 6 8

  21. Quantitative combinations of criteria Basic approach 0 4 7 9 2 1 3 5 6 8 Cost per DALY (multiples of GNI / capita) Overlap Approach 0 4 7 9 2 1 3 5 6 8

  22. Health gains & financialprotection- per $1M

  23. Health gains & financialprotection- per $1M

  24. Health gains & financialprotection- per $1M

  25. Health gains & financialprotection- per $1M

  26. Health gains & financialprotection- per $1M

  27. Health gains & financialprotection- per $1M

  28. Health gains & financialprotection- per $1M

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